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Karus, A., Praakle, K., Saar, T., Must, K., Randoja, H. and Viltrop, A., 2018. Biosafety and biosecurity manual.

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Aseptic technique University of Edinburgh

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Aseptic technique University of Edinburgh

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The instrument trolley should stay in the dirty theatre until sterile supplies are ready to take 

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The instrument trolley should stay in the dirty theatre until sterile supplies are ready to take 

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the kit for processing. All infected kit is washed in the washer/disinfector, and all other kit

should be in sterile supplies to avoid cross-contamination.

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Washing should remove all the dirt and biological debris from the surface of the materials and should be performed within 30 minutes of the end of the surgical procedures. To prevent blood from drying on the materials we suggest covering them with a damp towel.

The instruments shouldn't be overexposed to physiological saline solutions, since prolonged contact promotes oxidation.

At the beginning of the washing process the material should be rinsed under running water, while opening and closing the instruments. Manual washing should be done with hard plastic brushes, with the instruments immersed in demineralised or distilled water with enzymatic detergent at a neutral pH, under 45ºC, in order to avoid the coagulation of protein substances. We recommend always using new detergents and washing solutions since the overuse increases chemical concentration due to evaporation, favouring the corrosion of the materials and reducing the effectiveness of the disinfection.

Ultrasonic cleaning by cavitation is the most effective cleaning method.

Disinfection can be effectively achieved by immersing the instruments in enzymatic detergent, at neutral pH, for 90 minutes at 25°C. At the end the instruments should be rinsed with demineralised or distilled water and dried with paper towels. Do not use alcohol when cleaning materials.
2. Lubrication
Cleaning may render instrument's joints stiff due to mineral deposits and other impurities in the water system and regular metal to metal friction causes corrosion. Blue recommends applying a spray lubricant to all surfaces and instrument joints after each cleaning cycle.
3. Inspection
Before carrying out the sterilisation inspect each instrument and confirm the correct function of the joints, cleanness and general condition of the material.
4. Sterilisation
Sterilisation is essential to ensure that surgical instruments do not act as pathogen vectors. The most common method is autoclaving.

In the autoclave the instruments must always be in the open position to allow the steam to reach all surfaces. Do not overload the autoclave trays, which would block the steam penetration. The temperature, cycle duration and pressure should be those recommended by the manufacturer.

Regardless of the steriliser class, complete drying of all instruments and implants should be assured to prevent their degradation. The use of dry heat is not recommended for the sterilisation process.

Unpackaged instruments should be used immediately. Packaged instruments should be stored in a dry, closed and warm place.

Cold sterilisation, with prolonged immersion in enzymatic detergents, can impair delicate instruments. Avoid using solutions with benzium ammonium chloride on instruments with tungsten.

Most problems with the instruments can be attributed to one or more of the following causes:

Improper cleaning and drying immediately after use;

Prolonged exposure to sterilisation solution or use of corrosive solution;

Using normal running water instead of demineralised or distilled water in the cleaning and sterilisation processes;

Using non-recommended detergents or lubricants;

Some sort autoclave failure.

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1. Cleaning and Disinfection Washing should remove all the dirt and biological debris from the surface of the materials and should be performed within 30 minutes of the end of the surgical procedures. To prevent blood from drying on the materials we suggest covering them with a damp towel.

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ABSTRACT: Stainless steel surgical instruments are found in every veterinary practice, and can add up to a major investment. A good instrument care protocol, which everyone understands and follows, will maintain the instruments in good working order and prolong their useful life. The purpose of this article is to explain the necessary steps in this protocol and why they should be followed. And what can happen if they are not!

One of the largest investments in veterinary practice - and one which is used continually - is the surgical instrument set-up. This will comprise a range of equipment, the make-up of which will depend on the surgical caseload of the particular clinic.

Every practice will have basic soft tissue instruments; most will have some orthopaedic basics, along with more general surgical instruments, such as abdominal retractors. At the other end of the spectrum, the large referral hospitals will require a wide range of instruments covering multiple specialities.

Dental instruments should also be regarded and treated as surgical instruments, requiring the same level of care to maintain optimum performance.

Stainless steel

The majority of multi-patient autoclavable surgical instruments are made of stainless steel. There are many different types of stainless steel alloys, containing varying amounts of nickel and chromium to increase resistance to corrosion.1 All types of stainless steel will corrode under certain conditions - so the term 'stainless' is a little misleading.

The proportions of the various constituents will affect the characteristics of the final steel, particularly its resistance to corrosion and ability to take and keep an edge, along with the degree of hardening applied.1

Steel instruments are raised to very high temperatures and cooled during the hardening phase of the manufacturing process. This increases the strength and resistance to bending of the steel, but at the same time makes it more brittle.

Surgical instruments, such as scissors, must be hard enough to take and keep a cutting edge; or must have a degree of flexibility, for example, artery forceps. The steel possessing these qualities contains less chromium and more carbon than orthopaedic implants.

Implants are made of steel with the primary characteristic of resistance to corrosion, which makes it too soft for instruments. The penalty is that this type of higher carbon stainless steel (called Martensitic) has a reduced resistance to corrosion and staining compared to some other stainless steels. However, correctly cared for, it will give many years of service.

Steel for surgical instruments is specified to BSEN1SO 7153-1:2001. 2 The parts of the steel likely to rust are protected by a thin layer of chromium oxide which is produced by the chromium part of the steel during a process called self passivation. Actions which encourage the production of chromium oxide minimise corrosion. Actions which either physically or chemically destroy this layer of chromium oxide encourage rusting or staining.2-3

Maximising the chromium oxide layer is the basis of sound instrument care.

This layer thickens with age and increases the resistance of your instruments to corrosion - in new instruments it is relatively thin. This is why you may have marking problems with new instruments (or repaired/re-polished ones) but your old ones are fine - new instruments will be more intolerant of inappropriate detergents, inadequate lubrication and the corrosive environment of the autoclave.3

Basics of instrument care

To keep your instruments in peak condition, there are some basic rules which should be followed:

* Handle your instruments with care - abuse such as dropping and scratching will all damage the surface of instruments and reduce their resistance to corrosion.

* Store with care - if instruments are stored damp, they will corrode. This includes in bags or boxes which have come out of the autoclave, damp. Equipment that is not used on a regular basis is better stored clean, dry and lubricated ready for sterilisation before use. Delicate instruments should be packed with protective tips and silicone storage box inserts (Figure 1) or in suitable racks to stop them rattling around. Always make sure heavy instruments are not stored on top of lighter equipment.

Figure 1: Autoclavable silicone-fingered box and silicone-tipped protectors

* Use them to do what they were designed for! Artery forceps are not needle-holders or wire twisters, bone cutters are not designed to cut wire, and implant cutters have a size rating for a reason! Inappropriate use will damage instruments and invalidate warranties - and cost money to replace!

* Avoid mixing different metals when processing instruments - keep chrome-plated, industrial finish and aluminium items separate from stainless steel, particularly in ultrasonic cleaners.3

The basic decontamination cycle for surgical instruments is shown in Figure 2. Each stage of this should be followed for best results.

Figure 2: Autoclavable silicone-fingered box and silicone-tipped protectors

Cleaning of instruments

Manual cleaning of instruments requires minimal equipment. A basic protocol is shown in Table 1.

A range of suitable brushes is useful. These should be soft nylon for most instruments, and include fine tube brushes for instruments with a lumen, such as drill guides. Pipe-cleaners can. also be useful.

For drills, reamers and spinal burs, stainless brushes can be used. These should only be of fine stainless wire and be specifically supplied for instrument cleaning.4 Rasps may require a heavier duty brush, sometimes listed as 'orthopaedic' in catalogues.4 Most instrument suppliers list a range of suitable brushes. Heavy duty domestic or industrial wire brushes shou
ld not be used as they will destroy the surface of the instrument, resulting in increased corrosion.

Instrument cleaning solutions must be used at the correct dilution and duration of contact as specified by the manufacturers. Suitable products include Rapidex and Rapizyme (Rapidex), Medizyme (Medichem International) but there are many others to choose from. These are low-foaming enzyme-based products, which can also be used in ultrasonic units and they efficiently remove organic residues prior to sterilisation.

Make sure the solution you use is correct for the metal you are cleaning. Using a stainless steel stain remover on plated items will strip the plating (Figure 3).

Figure 3: Coating stripped from drill bit by acid stainless steel surface stain remover

Ultrasonic instrument cleaners are very useful in an instrument care protocol.3 These will allow thorough cleaning of areas which are otherwise impossible to reach with brushes, such as the lumen of fine instruments and the inner surfaces of box joints. This will remove build-up within joints, which causes stiffening over time (Figure 4). They are also the most efficient way to clean burrs and reamers, and they do not damage the cutting edges.

Figure 4: Long-term biological debris build-up within joint. End result - instrument failure!

Instrument washer/disinfector units, which are the norm in human instrument reprocessing, are now becoming available in the veterinary market. New guidelines for dental practices also recommend use of these as best practice.5

These machines are designed to clean instruments thoroughly, and usually have lumen flushing attachments for dental hand-pieces and similar instruments. They also incorporate a thermal disinfection stage during which the load is held at 90°C for one minute. Washer- disinfectors allow for documentation and validation of cycles.

If you make the decision to go down this route, select a machine which is compliant with HTM 01-05 and EN ISO 15883 as a minimum. Cleaning and sterilising guidelines in human healthcare are covered in HTM 2030, HTM 2010 and BS EN ISO 17665-1.

Visual checking and lubrication

Once cleaned, instruments are ready for lubrication. Always carry out a visual check at this stage - are the cutting edges of scissors free of damage, do the jaws of artery forceps and needle-holders meet correctly with no signs of twisting, for example? Check that all thumbscrews are tight in instruments, such as Gelpi retractors and stifle distractor joints.

Check for fine cracks in instruments, for example, across the box joints in artery forceps. Leave all joints and ratchets open for lubrication and sterilisation, as this will allow steam and lubricant to access all surfaces and prevent strain on joints caused by heat expansion in the autoclave, if the instrument is under tension.

Damaged items should either be disposed of or be sent for repair. Items being sent for repair must be decontaminated by cleaning thoroughly and then sterilised. If necessary, these items can be marked using plastic tags prior to processing, so they do not inadvertently go back into the normal instrument kit.

Repairers usually require a certificate of decontamination to be sent with instruments, and instruments should never be sent out in a soiled condition.

Lubrication should not be forgotten - either an 'instrument milk' bath such as Eezee-lube (Medisave) or an instrument oil (Instol instrument lubricant spray, Aesculap Sterilit instrument oil and spray). This is an essential - and often overlooked - part of the care cycle.

There are many materials available for packing instruments for autoclaving. Paper peel-packs are commonly used, along with nylon autoclave film. Laundered fabrics used as instrument wraps can cause problems, because residual detergents and bleaches can cause pH- and chloride-related damage to the instruments. Disposable non¬woven autoclavable instrument wrapping material similar to disposable drapes are available.

Make sure the packaging you use is suitable for your autoclave, and use appropriate indicators to monitor the process. Fabric-wrapped packs in a non vacuum autoclave may result in poor steam penetration, so monitor the process very carefully.

The autoclave is a very hostile environment for your instruments. The combination of heat and moisture promotes corrosion and staining, particularly if there are residual detergents in wrapping materials. This is also true where tap water, instead of distilled or demineralised water, is used in the autoclave.

Mineral deposits on instruments are unsightly and can interfere with normal joint function. They are difficult to remove, so prevention is better than cure. Chloride ions from water treatments and laundry detergents, as well as those from organic contaminants, can build up and damage the surface of the instrument, causing pitting.

Rust and contaminants in the steam pipes of your autoclave will transfer to your instruments, so autoclave maintenance is important. Regular servicing ensures the autoclave is working correctly. Vacuum autoclaves help remove residual steam from packs but it is important that directions are followed and cycles are completed.

Regularly check that the door seal is undamaged, and replace it if necessary. Drain and refill the water tank regularly with distilled water, unless your machine does this automatically. You may well be surprised what comes out!

If your packs are coming out of the autoclave wet, then there is a cycle problem and you need to speak to your autoclave engineer for advice. Wet storage will result in corrosion and damage to your instruments.

So - store your instruments clean, dry, lubricated and protected and they will give you many years of service. A good, easy-to-follow instrument-care protocol will extend instrument life, save money and result in happy surgeons!

Linda Capewell VN

Linda qualified in 1988 after 10 years in practice with the PDSA in Sheffield, as one of the first group of the charity's VNs. She spent a total of 26 years with the PDSA, and then in 2004 she left and joined Veterinary Instrumentation as veterinary technical support manager. She now deals with a wide range of queries every day.

To cite this article use either

DOI: 10.1111/j.2045-0648.2012.00173.x or Veterinary Nursing Journal Vol 27 pp 173-176

References

1.British Stainless Steel Association. How many types of stainless steel are there? http://www.bssa.org.uk/faq.php?id=10 Accessed February 2012

2.British Stainless Steel Association. Selection of stainless steel for surgical instruments http://www bssa.org uk/topics php?article=132 Accessed February 2012

3.Instrument Preparation Working Group. Proper Maintenance of Instruments in Veterinary surgeries. Germany 2006. http://www a-k- i.org/index.php?id=13&L=1

4.Veterinary Instrumentation. Current catalogue. Sheffield

5.Department of Health. Decontamination - Health Technical Memorandum 01-05: Decontamination in primary care dental practices London 2009

Further reading

Department of Health NHS Estates. A guide to the decontamination of reusable surgical instruments 2003. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4120907.pdf

Surgical instrument care sheets - many online manufacturer references [See reference 5 above]

* VOL 27 * May 2012 * Veterinary Nursing Journal

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Care and maintenance of surgical instruments by Linda Capewell - British Veterinary Nursing Association

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ABSTRACT: Stainless steel surgical instruments are found in every veterinary practice, and can add up to a major investment. A [...]

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Cleaning and Disinfection Biosecurity Tip Sheet (iastate.edu)Cleaning and Disinfection Biosecurity Tip Sheet (iastate.edu)

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Proper health equipment management requires significant attention to detail. Establishing and following protocols during processing (eg, cleaning and disinfecting equipment at the end of the work day) is required to ensure a safe product that is free of defects and residues. Overall cleanliness of equipment and facilities is important not only from a food safety standpoint but many view these as an overall indicator of attention to detail in the entire production system. Ensuring that needles are changed, implant guns are managed properly, vaccine is handled in an acceptable manner, and that proper chute operation occurs is essential.

Keywords: Animals, Health, Equipment, Management

Key points

Establishing and following protocols during processing is required to ensure producing a safe product that is free of defects and residues.

In this age of increasing production transparency, overall cleanliness of equipment and facilities is important not only from a food safety standpoint but many view these as an overall indicator of attention to detail in the entire production system.

Ensuring that needles are changed, implant guns are managed properly, vaccine is handled in an acceptable manner, and proper chute operation occurs is essential.

Sanitation and proper use of animal health equipment used in processing and treatment of beef cattle should be a primary concern of both veterinarians and producers to ensure product quality and safety. Bacterial and viral nosocomial infections can occur in cattle as a result of improper sanitation of facilities and equipment.¹ Zoonotic illnesses can occur in animal caregivers as a result of improper sanitation. Environmental contaminants such as Escherichia coli and Salmonella spp are spread between cattle by improperly sanitized equipment.¹ Improper injection location, changing of needles, and inadequate cleaning of syringes can lead to injection site blemishes, scar tissue, or bacterial infections, which affect the quality and safety of the end product. 2, 3

Biosecurity: isolation, traffic control, and sanitation

The goal of a biosecurity plan is to prevent or control cross-contamination of feces, urine, saliva, and so forth between animals to prevent or control the spread of pathogens between animals.⁴ This plan should consider direct as well as indirect animal contact. Indirect contact considerations include animal to feed transmission and animal to equipment transmission. The 3 components of biosecurity are isolation, traffic control, and sanitation.

Isolation is the most important step in disease control, because it prevents direct contact between diseased or potentially infected cattle and healthy cattle. Preventing commingling of new cattle and existing groups of cattle is crucial to an effective biosecurity plan. Facilities used to segregate cattle should be cleaned between groups and disinfected if deemed appropriate.

Traffic control includes all traffic on an operation, animals, people, and vehicles or equipment. Animals to consider include all domesticated animals as well as rodents, birds, and other wildlife. Fecal contamination of feedstuffs such as silage or ground hay can be controlled by limiting traffic to the silage pit and hay pile to the loader designated to load feed. Another major concern of traffic control is limiting rendering truck access to an area of the yard that is away from all cattle and feeding activities.

Sanitation refers not only to the disinfection of people and equipment entering an operation but the cleanliness of people and equipment on the operation. Prevention of fecal-oral contamination is the primary goal of sanitation. Balling guns and drench guns are of primary concern for disinfecting between animals. Before disinfection, the equipment should be cleaned with soap and hot water at the end of each day and stored in a dry area.

Another major biosecurity consideration is loaders that are used to load feedstuffs. If these loaders are used for handling manure, dead cattle, or other nonfeedstuff products, they should be cleaned and disinfected before loading feedstuffs. Processing and treatment areas should be cleaned at the end of each day. This strategy reduces the likelihood of fecal-oral contamination not only of the cattle but of the caregivers as well.

The first step in sanitation is the removal of organic matter, primarily feces. Any blood or saliva present should also be removed. Disinfection should follow this cleaning. Physical contact between the disinfectant and proper contact time are crucial to ensure proper disinfection. The selected disinfectant should kill a broad spectrum of bacteria, viruses, protozoa, fungi, and spores.⁵ Other selection considerations include safety to both humans and animal, effect on equipment (corrosiveness), effect on environment, and cost ( Tables 1 and ​and2 2 ).

Table 1

Compound

Chlorine 0.01%-5%

Iodine Iodophor 0.5%-5%

Chlorhexidine 0.05%-0.5%

Alcohol 70%-95%

Oxidizing 0.2%-3%

Phenol 0.2%-3%

Quaternary Ammonium 0.1%-2%

Aldehyde 1%-2%

Adapted from Bek TJ, Griffin D, Kennedy J. Selection and use of disinfectants. NebGuide G1410: Cooperative Extension, Institute of Agriculture and Natural Resources, University of Nebraska-Lincoln; 2000 and Data from Refs. 5, 6, 7, 8, 9

Table 2

Virus

Envelope

Virus

Envelope

Virus

Envelope

From Bek TJ, Griffin D, Kennedy J. Selection and use of disinfectants. NebGuide G1410: Cooperative Extension, Institute of Agriculture and Natural Resources, University of Nebraska-Lincoln; 2000.

Veterinary equipment sanitation

Equipment used for processing and treating cattle should be cleaned and disinfected daily, after use. If this equipment becomes grossly contaminated with feces or other material while being used, it should be cleaned immediately.

Equipment such as balling guns and drench guns should be thoroughly cleaned at the end of each day and stored in a clean, dry environment. Disinfecting this equipment between animals is recommended. The disinfectant solution should be changed when it becomes cloudy or visibly contaminated to maintain effectiveness. Increased morbidity and mortality in feeder cattle have been associated with improper sanitation of this equipment in a feedyard hospital system having a high prevalence of Salmonella infection.¹ Cohort cattle that did not go through the hospital system were found to have zero prevalence for Salmonella spp.

Disinfecting of blood-contaminated equipment between animals is essential. This strategy reduces the risk of transmission for pathogens such as bovine virus diarrhea virus, bovine leukosis virus, and various other blood-borne pathogens. Disinfection also reduces bacterial contamination and risk of disease transmitted animal to animal. This equipment includes dehorners, castration equipment, and various instruments used for minor surgical procedures. Thorough cleaning is necessary, followed by storage in a clean, dry area. Banding castration equipment should be kept free of feces and other gross contaminates between animals. Thorough cleaning at the end of the day is appropriate.

Cleaning and disinfection of obstetric equipment is an often neglected area. All obstetric equipment, calf pullers, chains, straps, head snares, and so forth should be thoroughly cleaned and disinfected after each use. If straps are being used rather than chains, extra attention should be given to making sure that the strap is clean and dry before storing. Chains should be allowed to dry completely before storing to prevent rusting.

One of the most consistent, positive returns on investment procedures in the cattle industry is the use of growth-promoting implants. For this practice to be effective, care must be taken to ensure that it is performed properly. Implant guns should be thoroughly washed with detergent and hot water after each use and allowed to dry. It is essential that the needles on these guns are sharp. If needles become dull or burred, they should be discarded rather than attempting to sharpen them. The ear should be free of feces and other gross contamination. If not, the ear should be cleaned with a disinfectant solution before placing the implant. A sponge or paint roller in a disinfectant solution should be available to clean the implant needle after each animal is implanted. If the needle skips off the ear, the needle should be disinfected before another attempt to implant is made.

Care and cleaning of veterinary vaccine syringes

Inadequate care and cleaning of syringes used for routine vaccination of livestock can be associated with localized swelling and infection after vaccination.² Swellings involving the injection site are common, particularly when vaccines such as clostridial vaccines are given subcutaneously. The subcutaneous use of oil-adjuvanted vaccines also results in swelling of the injection site. If these swellings do not subside in a short period, if they become larger than a small hen's egg, or if they become fluid filled, they may be infected and should be examined.²

Proper cleaning of syringes begins with using hot water, soap, and a brush to clean the external surface and working mechanism of the syringe. Care should be taken to keep soap away from the luer tip of the syringe. After cleaning the external components, rinse the internal components with distilled or deionized water that is warmer than 82.2°C (180°F) by drawing the water into the syringe and squirting it out several times.² All syringes, whether pistol grip repeaters or continuous feed syringes with vinyl tubing and vent spikes, can be cleaned in this manner. Soap and disinfectant should not be used on the internal components of syringes. Remove as much water as possible from the syringe and allow it to cool before use, because heat inactivates modified live viral vaccines. Some syringes may need to be disassembled to adequately clean them. Disassembly should be performed on a clean work surface followed by cleaning the components with hot tap water, avoiding the use of soap or disinfectant. If syringes are physically contaminated enough to require disassembly for cleaning, they should be boiled for 5 minutes in deionized or distilled water. Plastic, continuous feed syringes can be sanitized after cleaning, if necessary. The syringe and tubing should be filled with distilled water and wrapped in multiple layers of paper towels. After soaking the paper towels in water, the syringe is placed in an unclosed zip-lock bag. This bag is placed in a microwave oven for 5 minutes using the high setting. Care should be taken that the paper towels do not dry out during this process. Syringes should be individually microwaved when using this method. After the syringes are removed from the microwave, any water remaining in them should be squirted out and the syringe allowed to cool before using.

Syringes should be reassembled while hot, using lubricant such as vegetable oil spray on the rubber plunger.² Others recommend using the first draw of vaccine as the lubricant, thus avoiding silicone, mineral oil, or Vaseline.¹⁰ There does not seem to be a consensus as to what is acceptable (nonviricidal) in regard to syringe lubricant, because still others recommend the use of silicone or Vaseline.¹¹ This is an area that warrants further investigation.

Once assembled, the syringe should be rinsed several times with water warmer than 180°F. After cooling, the syringes should be stored in a clean, dry environment, such as a new zip-lock bag that is placed in a freezer. Syringes should be allowed to warm to room temperature before filling with vaccine. Warming the syringes by artificial means may result in hot spots in the syringes, which have the potential to damage the vaccine.

Syringes should be labeled to ensure that the same product goes in each syringe every time cattle are worked. This strategy eliminates the possibility of trace amounts of a vaccine or pharmaceutical remaining in a syringe and having a detrimental effect on the next product in the syringe. It also ensures that syringes are not filled with the wrong product during processing.

Transfer needle management

Transfer needles should be cleaned in a manner similar to syringes, after using a stylet to remove rubber plugs from the needle, using hot water without soap or disinfectant. Once cleaned, there are several methods that can be used to ensure that the needles are sterile. These methods include²

1.

Boiling in distilled water for 5 minutes. After cooling, the needles should be stored in a clean, dust-free container.

2.

Microwaving the needles in a cup filled with distilled water. Use the high setting to bring the water to a boil. Once the water boils, continue for 1 minute. Be sure the needles are completely covered with water during the entire process. Once again, the needles should be stored in a clean, dust-free container after cooling.

3.

Wrap the needles in several layers of paper towels. Soak the paper towels in water and place in a zip-lock bag. Place the unclosed zip-lock bag in a microwave for 2 minutes using the high setting. The paper towels should remain wet during the process. Store appropriately when cool.

4.

Autoclaving works well if such equipment is available. The clean needles are placed in a 12-mL disposable syringe case or multiple needles in a 20-mL syringe case. The cap is held in place with autoclave tape. After autoclaving, the syringe cases work well for clean, dust-free storage.

Needle selection and management

The size of needles used for processing and treatment of cattle should be adjusted according to cattle size, viscosity of product injected, route of administration, and type of restraint to be used ( Table 3 ). Use the smallest needle possible to easily administer the product, yet large enough to prevent the needle from bending or breaking off in the animal. The use of disposable needles is recommended, because they are sterile and are sharp. Using steel needles that are reusable is discouraged, because they are difficult to sterilize and keep sharp. Improper needle management results in injection site lesions that requires trimming during harvest or fabrication.¹²

Table 3

Route of Administration

SQ (0.5-0.75 inch Needle)

IV (1.5 inch Needle)

IM (1-1.5 inch Needle)

Cattle Weight

Cattle Weight

Cattle Weight

Injectable viscosity

<300

300-700

>700

<300

300-700

>700

<300

300-700

>700

Thin (gauge)
Example: Saline

18

18-16

16

18-16

16

16-14

20-18

18-16

18-16

Thick (gauge)
Example: Oxytetracycline

18-16

18-16

16

16

16-14

16-14

18

16

16

Adapted from Beef quality assurance. Best management practices-prevention and processing. National Beef Quality Assurance manual. National Cattlemen's Beef Association, Centennial, CO.

Needles should be changed before they become dull, preferably every 10 to 15 head. In addition, they should be changed immediately if the needle bends, becomes contaminated with feces, dirt, or chemicals, or if the needle point is damaged. In herds that are known to be infected with pathogens that are blood borne, consideration should be given to changing needles after each animal. Never use a needle that is bent, because this increases the likelihood that the needle will break off in the animal being injected. It is considered an emergency situation when a needle breaks off in an animal. If this occurs, great effort should be made to find the needle immediately. If the needle cannot be found, the animal should be identified to be checked later. An animal that is known to have a broken needle in it should not be marketed for human consumption.

The best method for disposal of used needles is the collection of needles in a biohazard sharps container, which should be disposed of by a biomedical disposal company. An alternative disposal method is collecting the needles in a plastic jug or bucket and filling the bucket with cement powder and water before sealing it and disposing of it in a landfill. Used needles should never be disposed of individually in the daily trash. State law should be checked if one is unsure of the legalities of needle disposal in one's local area.

Vaccine storage and handling

For vaccines to induce adequate immunity, they must be shipped, stored, and handled in a proper manner, including the handling that occurs during administration. Although this factor is especially important for modified live vaccines, it applies to all vaccines whether modified live virus, killed virus, or a bacterin toxoid.

Refrigerators used to store animal health products come in all shapes and sizes, ranging from minirefrigerators to household-type refrigerators to glass-front display coolers. Many of the household-type refrigerators are used refrigerators purchased for the sole purpose of storage of animal health products. These refrigerators are found in a variety of places from the barn, to the shop, to the mudroom, or even the kitchen. Retailers such as feed stores and veterinary clinics are another common location for refrigerators used to store animal health products.

Two studies funded by state Beef Quality Assurance programs have evaluated how well these refrigerators cool. The first study evaluated 191 refrigerators.¹³ Of these refrigerators, only 51 (26.7%) operated within the desired temperature range greater than 95% of the time over the 48-hour test period. Thirty-eight (19.9%) operated at the correct temperature 66% to 95% of the time, whereas 34 (17.8%) operated properly 36% to 65% of the time and 23 (12.0%) were in the correct range 5% to 35% of the time. The remaining 45 refrigerators (23.6%) operated at the desired temperature less than 5% of the time. Nearly 43% of these 191 refrigerators were greater than 10 years old. The second study evaluated 176 refrigerators.³ Producer refrigerators accounted for 129 of the 176, whereas 47 were feedstore or veterinary clinic refrigerators. Forty (31%) of the 129 refrigerators operated at the correct temperature greater than 95% of the time, with another 19 (14.5%), operating properly 66% to 95% of the time. Forty-three (33.3%) were at the correct temperature less than 5% of the time. The retail coolers were similar, in that 16 (34%) were at the correct temperature greater than 95% of the time. Seven (14.9%) operated properly 66% to 95% of the time and 10 (21.3%), were at the correct temperature 36% to 65% of the time. Eight (17%) were found to be at the proper temperature less than 5% of the time.

The desired temperature range as defined for these studies was 2°C to 7°C (35°F-45°F), which is the temperature range commonly recommended by the pharmaceutical industry. Temperatures lower than 2°C (35°F) can be more detrimental than temperatures higher than 7°C (45°F) because of antigen-adjuvant separation.⁹ Temperatures higher than 7°C (45°F) are particularly detrimental to modified live vaccines.

Location of the refrigerators in this study seemed to account for a portion of the fluctuation of the temperature. Those refrigerators that were in a controlled environment maintained proper temperature in a more acceptable manner than did those that were located in an uninsulated building.

An interesting observation in these studies was the number of outdated products and open bottles of product, including modified live viral vaccine, that were found in the refrigerators evaluated. Of the 1800 products found in producer refrigerators in the first survey,¹³ 11.8% were outdated and 29.3% were open. The second survey¹⁴ found nearly 2260 products in the refrigerators, of which 20.5% were expired and 27.2% were open.

A summary of these 2 refrigerator studies includes the following:

1.

Keep a thermometer in the refrigerator so that temperature can be monitored.

2.

Do not use minirefrigerators for long-term storage.

3.

Keep the refrigerator in a controlled environment.

4.

Regular cleaning of the coil and compressor are essential, particularly if the refrigerator is located in a barn or processing shed.

5.

Refrigerators that do not maintain temperature between 2°C and 7°C (35°F - 45°F) should be replaced.

When vaccine is taken from the refrigerator to chute-side, it should be stored in a cooler box with freezer packs. This strategy not only keeps the vaccine cool but provides for storage of the vaccine out of direct sunlight once it has been mixed. No more modified live viral vaccine should be mixed than is anticipated will be used in 1 hour. Open vaccine, whether modified live or killed, should be stored in the cooler box unless syringes are being filled. Modified live vaccine that has been mixed should be discarded when the cattle have been processed, because of the short life of the vaccine (≤1 hour).

Care should be taken to ensure that a used needle never enters a bottle of vaccine. A used needle can contaminate the remainder of the vaccine, resulting in injection site blemishes. The importance of cleanliness during processing is shown by the fact that dried nasal secretions from a calf persistently infected with bovine virus diarrhea (BVD) virus on the rubber stopper of a vaccine bottle transmitted BVD virus to a seronegative calf.¹

The storage environment of nonrefrigerated pharmaceutical products such as antibiotics, anthelmintics, and topical insecticides should be considered. These products should be protected from freezing and heat, because either can cause damage to the product. If the rubber stoppers on stored bottles of product are damaged enough to not seal the bottle, the product may deteriorate because of exposure to air. These bottles should be capped in some manner, such as a roll-on rubber stopper, to prevent exposure of the product to air.

Hydraulic chute management

The operating pressure and thus the operating speed of a hydraulic chute are set by the manufacturer and should not be changed. Although this pressure setting varies between manufacturers, the basic guideline is 272 kg (600 lb) of squeeze pressure measured at the bottom of the squeeze panel drop gates using a pressure bar between the 2 squeeze panels (D.D. Griffin, personal communication, 2015). For this pressure to be accurate, the distance between the bottom of the squeeze panels should be slightly narrower than the distance between the squeeze panels at the bottom of the drop gates (simulate shoulder width vs stance width).

The chute operator should always use 2 hands on the controls. This technique allows for smoother handling of the cattle and reduces the bruising that can be associated with processing. Before cattle enter the chute, the distance between the bottoms of the squeeze panels should be observed. This distance should be approximately the stance width for the class of cattle being processed. If this distance is too narrow, excessive pressure will be applied to the animal when the squeeze is applied. As the operator prepares to let cattle enter the chute, the tailgate is opened with the squeeze slightly closed and the headgate open no wider than the animal's shoulders.

As the animal proceeds into the chute, it is slowed with the squeeze panels to prevent it from slamming into the headgate. The headgate is closed, the tailgate closed and then, if necessary the squeeze panels. When releasing the animal, the headgate should be opened first, then the squeeze released. When this sequence is followed, the cattle tend to move forward, without the use of an electrical prod. If the squeeze is released before opening the headgate, the cattle tend to back up, necessitating prod use in many instances. The use of low-stress handling practices before the animal enters the chute can reduce the risk of injury and problems associated with hydraulic chute use.

Summary

Proper health equipment management requires significant attention to detail. Establishing and following protocols during processing (eg, cleaning and disinfecting equipment at the end of the work day) is required to ensure a safe product that is free of defects and residues. In this age of increasing production transparency, overall cleanliness of equipment and facilities is important not only from a food safety standpoint but many view these as an overall indicator of attention to detail in the entire production system. Therefore, ensuring that needles are changed, implant guns are managed properly, vaccine is handled in an acceptable manner, and proper chute operation occurs is essential.

Footnotes

The author has nothing to disclose.

References

1. Thomson D.U. Feedlot hospital management. In: Anderson D.E., Rings D.M., editors. Current veterinary therapy: food animal practice. Saunders; St. Louis (MO): 2009. pp. 678-681. [ Google Scholar]

7. Boothe H.W. Antiseptics and disinfectants. Vet Clin North Am Small Anim Pract. 1998;28:233-248. [[ PubMed] Google Scholar]

8. Cleaning and disinfection of environmental surfaces. Health Care Health and Safety Association of Ontario; 2004. [ Google Scholar]

12. Dexter D.R., Cowman G.L., Morgan J.B. Incidence of injection-site blemishes in beef top sirloin butts. J Anim Sci. 1994;72:824-827. [[ PubMed] Google Scholar]

13. Troxel T.R., Barham B.L. Case study: the temperature variability of refrigerators storing animal health products. Professional Animal Scientist. 2009;25:202-206. [ Google Scholar]

14. Fife T.E., Troxel T.R., Barham B.L. Case study: handling and management of animal health products by Idaho producers and retailers. Professional Animal Scientist. 2013;29:313-320. [ Google Scholar]

Articles from The Veterinary Clinics of North America. Food Animal Practice are provided here courtesy of Elsevier

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Proper health equipment management requires significant attention to detail. Establishing and following protocols during processing (eg, cleaning and disinfecting equipment at the end of the work day) is required to ensure a safe product that is free ...

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dvs-infection-control-and-biosecurity.pdf

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Biosecurity encompasses everything that is done to mitigate pathogens and protect against the spread of infectious diseases. Cleaning, sanitizing, disinfecting and sterilization each play a vital role in the overall protection of animal, human and environmental health. To address the unique needs in veterinary practices multiple strategies and processes are required to be effective but it doesn't have to be complicated. Approach each cleaning process in the same manner. The number and type of layers is determined by the desired outcome.
Base Layer
Always start with Macro Cleaning any surface by manually removing potential fomites and/or organic material such as feces, urine, gross debris, bedding, gauze pads, surgical instruments, drapes or other items that have the potential to spread germs. Make sure all items are placed in designated receptacles with covers where appropriate.
Cleaning Layer
Thorough cleaning is required prior to disinfection and sterilization to remove visible foreign matter from objects and surfaces. Inorganic and organic materials that remain on the surface interfere with the effectiveness of these processes.

Choose a cleaner with surfactants (soap or detergents) that has good cleansing properties when in dilute solutions to remove dirt, dust, stains, soils and associated odors from surfaces. Don't overlook that water is considered the universal solvent and is essential to most cleaning processes. Presoaking instruments, laundry, or surfaces with dried fecal material or blood dramatically improves results.

Friction is also extremely important. Scrubbing helps break down grime and assists with the removal of debris, allowing it to be more readily removed by ultrasonic cleaning, rinsing &/or wiping and better prepares the object for sanitizing, disinfection or sterilization. For instruments with channels too small for the bristles to reach pressurized fluids are used to dislodge soil and debris.
Sanitizing Layer
Sanitizing reduces or eliminates the number of pathogenic agents (such as bacteria) on surfaces to a safe level. This is often preferred for low-risk areas such as daily routine cleaning of a pet boarding kennel where the same occupant resides during its stay. This lessens the potential exposure to strong chemical agents, fumes and residues.
Disinfecting Layer
Disinfection eliminates harmful viruses and bacteria, except for bacterial spores, that remain on surfaces after cleaning. This should be used in all circumstances that are considered high or unknown risks and for deep cleaning of low-risk areas such as preparation for a new patient or high contact surfaces.
Sterilizing Layer
Sterilization kills all microorganisms from surfaces. Physical or chemicals methods such as pressurized steam, dry heat, ETO gas or liquid chemicals are used for surgical applications such as instruments, equipment and surgical packs.
Protection Layer
Unfortunately, as soon as the disinfection process is complete any exposed surfaces are immediately at risk for recontamination from potential pathogens in the air. Air Purification provides protection against airborne pathogens, however, not all air purifiers are the same. When choosing an air purifier look for an active system such as Photocatalytic Oxidation technology that releases ions into the environment to inactivate pathogens midair and on exposed surfaces. This will augment your sanitizing and disinfecting processes.
Other Considerations
Always check the Safety Data Sheet for every chemical to ensure it is safe and what, if any, hazards are associated with potential exposure or chemical interactions. To minimize risks, use complimentary chemistry's, always use per label directions and wear Personal Protective Equipment (PPE) as needed.

Prioritize frequent cleaning, disinfection and protection of rooms, high contact surfaces and frequently used equipment. Limit exposure by using disposable patient care equipment and supplies when possible.

Encourage frequent hand washing, use of hand sanitizers and changing of gloves.

Take advantage of resources provided by biosecurity experts in animal health.
Finally Set Expectations
Emphasizing the importance of good biosecurity practices is imperative to a successful business, especially those in the medical field. Collaborate with staff members to optimize current protocols and processes and help them become vested in their successful execution.

Not only will this lessen the potential of disease transmission but will improve employee morale, decrease costs associated with outbreaks, elevate standing in the community and optimize patient care.

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Effective Biosecurity Requires a Layered Approach - Ogena Solutions

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Biosecurity encompasses everything that is done to mitigate pathogens and protect against the spread of infectious diseases. Cleaning, sanitizing, disinfecting and sterilization each play a vital role in the overall protection of animal, human and environmental health. To address the unique needs in veterinary practices multiple strategies and processes are required to be effective but [...]

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cvs-ltd-infection-control-and-biosecurity (1).pdf

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Presentation accompanying RCVS Knowledge podcast by Liz Branscombe and Pam Mosedale on infection prevention, and control policies and procedures in routine practice.

Your download should start automatically. If not download directly.

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Presentation - Infection prevention, and control policies and procedures in routine practice

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Presentation accompanying RCVS Knowledge podcast by Liz Branscombe and Pam Mosedale on infection prevention, and control policies and procedures in routine practice. Your download should start automatically. If not download directly.

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Handling and Care of Instruments

Modern surgical instruments are made of stainless steel, an alloy of iron, chromium and carbon. The inclusion of chromium increases the resistance to corrosion. With proper care and attention, surgical instruments will last for years.

In larger veterinary hospitals it may be necessary to have a number of general surgical packs, with additional specialized instruments packed separately. A card index system, outlining the equipment needed for each procedure, facilitates efficient preparation prior to surgery. Coloured tape may be used for identification of instruments from within the same set to allow for easy repackaging; however, this must be used with caution as it provides a useful "hiding place"for bacteria.

Care

Instruments should only be used for the purpose for which they were designed. Allis tissue forceps should not be used as bone holders and Metzenbaum scissors should not be used for cutting sutures!

Instruments should always be placed on surfaces, not dropped or thrown.

Heavy items should not be placed on top of, or adjacent to delicate equipment.

Instruments with cutting blades should be protected to avoid dulling of the edges.

Protective sheaths should be left in place until the instrument is ready for use.

During surgery, the scrubbed nurse (if utilising this role) should ensure that the instruments are kept free of blood and debris by wiping with a sterile moistened swab after each use.

Checks

Instruments should be checked after each procedure.

Check tungsten carbide inlays for burrs
Check both sides for cracks
Check correct fit of the screw link
Perform cutting test

Forceps/clamps

Check the jaws for damages, scratches and deformation
Check the jaws teeth, serration and tines
Cracks in the link
Check the teeth lock fully engage
Teeth have same measurement and fit nicely
Check the clamp cannot be opened

Needle holders

Check and test the lock
Check serration for damages
Check the rounding of inner jaw tips visually and physically with finger tips

Dissecting forceps

Check jaws for damages, deep scratches and deformation
Check spring for cracks
Check spring for tension
Spring must not be bent

Other recommended checks:

Ratchets should close easily and hold firmly.

Box locks that are too loose will cause misalignment and will not hold tissue securely. When not in use, the box locks should be left secured on the first ratchet.

The shaft of instruments, in most cases, should be straight to ensure correct alignment.

Cutting instruments (scissors, osteotomes, chisels, periosteal elevators and rongeurs) should be checked for sharpness and chips in the metal.

Protective sheaths should be applied for storage.

Needle holders become damaged when too large a needle has been used for the given size and type of needle holders. An appropriately sized needle will be gripped firmly with the jaws locked on the second ratchet. Some needle holders have tungsten carbide inserts, which increase strength and reduce wear on the gripping surface. These instruments are usually more expensive but they will last longer as the inserts can be replaced, therefore prolonging the life of the whole instrument. Instruments with tungsten carbide inserts are identified by their gold-coloured handles.

Titanium alloy is used for microsurgical and ophthalmological instruments. This alloy has a bluish colour that reduces glare under the operating lights. Such instruments are lighter and stronger than surgical steel instruments. Because of the design and physical properties of the instruments, the surgeon is able to control their movements much more easily. Extra care should be taken when handling these instruments because they are not only delicate, but are also expensive to replace. They can be placed in special trays for cleaning and storage.

Manual Cleaning

Before cleaning the surgical pack, the priority is the safe removal and disposal of all sharps! This is important to avoid sharp and needle stick injuries to the theatre nurse when cleaning and handling the instruments. Common sharps to look out for in surgical kits include scalpel blades (there could be more than one used) and various needles (especially swaged onto lengths of suture material).

Always clean instruments straight after use. If thorough cleaning is not possible, then at least rinse the instruments in cold water to remove gross dirt and blood. Hot water should not be used as it causes coagulation of proteins (e.g., blood). Instruments should not be soaked for prolonged periods as this is detrimental to the chromium oxide layer on the instrument surface, which may lead to staining and corrosion. If soaking is necessary, a chemical cleaning solution specifically designed for instruments may be used. Instruments should be cleaned using a detergent specifically designed for instrument cleaning as ordinary soaps and detergents can damage the surface of the instrument. Enzymatic cleaners are available which break down the dirt and grease. Instruments that have movable parts should be disassembled prior to cleaning (e.g., depth gauges and drill guides, etc.) All box locks and ratchets should be opened to ensure thorough cleaning.

Serrations and box locks should be cleaned with a soft bristle brush. Abrasive materials should never be used as they scratch the surface of the instrument, which may collect organic debris in later use and cause corrosion. A final water rinse will remove any traces of detergent prior to autoclaving.

Ultrasonic Cleaning

Ultrasonic cleaners are effective at removing debris from inaccessible areas such as box locks, serrations and deep grooves. These cleaners act by a process of cavitation. Ultrasonic energy produces high-frequency sound waves that generate tiny bubbles in the solution in the cleaner. The bubbles expand until they become unstable and collapse. This collapse generates minute vacuum areas that dislodge and dissolve debris.

The bath is filled to a level one inch above the tray. Only instrument cleaner recommended by the manufacturers should be used. The instruments are placed into a wire mesh tray (heavier, bulkier instruments at the bottom) and lowered into the bath. The tray should only be half full to avoid overloading and damage to the instruments. Instruments are thoroughly rinsed after ultrasonic cleaning to remove any surface debris and detergent residue.

Instrument Lubrication

Following cleaning and rinsing, all instruments with moving parts should be lubricated. Instrument manufacturers recommend the use of water-soluble lubricants such as instrument milk, an oil-in-water emulsion that has antimicrobial properties.

As a general rule, the instruments should be submerged in the lubricant bath for thirty seconds and then left to drain without rinsing or drying. However, if the instruments are to be sterilised in a hot air oven, then all traces of the lubricant should be removed as the intense heat causes the milk to form a "gum," which is difficult to remove.

Machine or mineral oils are not suitable as lubricants as they leave a sheen on the instrument surface and will inhibit steam penetration during the sterilisation process. Some instruments, such as orthopaedic drills, have their own silicone gel. This should always be used in accordance with manufacturer instructions.

Once the cleaning process has taken place, surgical instruments must be left to dry. Instruments must be laid out flat with any ratchets and hinges open to ensure adequate drying and reduce the risk of rust damage. Instruments are always air dried in a clean, low-traffic area to avoid contamination. Alternatively, a drying cabinet may be used. Use of a cloth or towel to dry surgical instruments will lead to accumulation of debris, which could harbour bacteria.

Sterilisation

Surgical instruments and equipment are sterilised before each and every subsequent use. The sterilisation process takes place after the instruments have been cleaned and are dry.

Heat Sterilisation

Autoclaves

This is the most widely used and efficient method of sterilisation and is also the most economical. Most items used within the veterinary practice can be autoclaved and include:

Instruments

Cloth drapes and gowns

Swabs

Most rubber articles - need to check with manufacturer/instructions

Some plastic goods - need to check with manufacturer/instructions

References

1. The Animal Industries Resource Centre Course materials - Certificate IV in Veterinary Nursing.

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Instrument Care Tips and Techniques - WSAVA 2018 Congress - VIN

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Handling and Care of Instruments Modern surgical instruments are made of stainless steel, an alloy of iron, chromium and carbon. The inclusion of chromium increases the resistance to corrosion. With proper care and attention, surgical instruments will last for years.

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Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments.

Cleaning is done manually in use areas without mechanical units (e.g., ultrasonic cleaners or washer-disinfectors) or for fragile or difficult-to-clean instruments. With manual cleaning, the two essential components are friction and fluidics. Friction (e.g., rubbing/scrubbing the soiled area with a brush) is an old and dependable method. Fluidics (i.e., fluids under pressure) is used to remove soil and debris from internal channels after brushing and when the design does not allow passage of a brush through a channel. ⁴⁴⁵ When a washer-disinfector is used, care should be taken in loading instruments: hinged instruments should be opened fully to allow adequate contact with the detergent solution; stacking of instruments in washers should be avoided; and instruments should be disassembled as much as possible.

The most common types of mechanical or automatic cleaners are ultrasonic cleaners, washer-decontaminators, washer-disinfectors, and washer-sterilizers. Ultrasonic cleaning removes soil by cavitation and implosion in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces. Bacterial contamination can be present in used ultrasonic cleaning solutions (and other used detergent solutions) because these solutions generally do not make antibacterial label claims ⁴⁴⁶. Even though ultrasound alone does not significantly inactivate bacteria, sonication can act synergistically to increase the cidal efficacy of a disinfectant ⁴⁴⁷. Users of ultrasonic cleaners should be aware that the cleaning fluid could result in endotoxin contamination of surgical instruments, which could cause severe inflammatory reactions ⁴⁴⁸. Washer-sterilizers are modified steam sterilizers that clean by filling the chamber with water and detergent through which steam passes to provide agitation. Instruments are subsequently rinsed and subjected to a short steam-sterilization cycle. Another washer-sterilizer employs rotating spray arms for a wash cycle followed by a steam sterilization cycle at 285°F 449, 450. Washer-decontaminators/disinfectors act like a dishwasher that uses a combination of water circulation and detergents to remove soil. These units sometimes have a cycle that subjects the instruments to a heat process (e.g., 93ºC for 10 minutes) ⁴⁵¹. Washer-disinfectors are generally computer-controlled units for cleaning, disinfecting, and drying solid and hollow surgical and medical equipment. In one study, cleaning (measured as 5-6 log ₁₀ reduction) was achieved on surfaces that had adequate contact with the water flow in the machine ⁴⁵². Detailed information about cleaning and preparing supplies for terminal sterilization is provided by professional organizations 453, 454 and books ⁴⁵⁵. Studies have shown that manual and mechanical cleaning of endoscopes achieves approximately a 4-log ₁₀ reduction of contaminating organisms 83, 104, 456, 457. Thus, cleaning alone effectively reduces the number of microorganisms on contaminated equipment. In a quantitative analysis of residual protein contamination of reprocessed surgical instruments, median levels of residual protein contamination per instrument for five trays were 267, 260, 163, 456, and 756 µg ⁴⁵⁸. In another study, the median amount of protein from reprocessed surgical instruments from different hospitals ranged from 8 µg to 91 µg. ⁴⁵⁹ When manual methods were compared with automated methods for cleaning reusable accessory devices used for minimally invasive surgical procedures, the automated method was more efficient for cleaning biopsy forceps and ported and nonported laparoscopic devices and achieved a >99% reduction in soil parameters (i.e., protein, carbohydrate, hemoglobin) in the ported and nonported laparoscopic devices. 460, 461

For instrument cleaning, a neutral or near-neutral pH detergent solution commonly is used because such solutions generally provide the best material compatibility profile and good soil removal. Enzymes, usually proteases, sometimes are added to neutral pH solutions to assist in removing organic material. Enzymes in these formulations attack proteins that make up a large portion of common soil (e.g., blood, pus). Cleaning solutions also can contain lipases (enzymes active on fats) and amylases (enzymes active on starches). Enzymatic cleaners are not disinfectants, and proteinaceous enzymes can be inactivated by germicides. As with all chemicals, enzymes must be rinsed from the equipment or adverse reactions (e.g., fever, residual amounts of high-level disinfectants, proteinaceous residue) could result. 462, 463 Enzyme solutions should be used in accordance with manufacturer's instructions, which include proper dilution of the enzymatic detergent and contact with equipment for the amount of time specified on the label. ⁴⁶³ Detergent enzymes can result in asthma or other allergic effects in users. Neutral pH detergent solutions that contain enzymes are compatible with metals and other materials used in medical instruments and are the best choice for cleaning delicate medical instruments, especially flexible endoscopes ⁴⁵⁷. Alkaline-based cleaning agents are used for processing medical devices because they efficiently dissolve protein and fat residues ⁴⁶⁴; however, they can be corrosive. ⁴⁵⁷ Some data demonstrate that enzymatic cleaners are more effective than neutral detergents 465, 466 in removing microorganisms from surfaces but two more recent studies found no difference in cleaning efficiency between enzymatic and alkaline-based cleaners. 443, 464 Another study found no significant difference between enzymatic and non-enzymatic cleaners in terms of microbial cleaning efficacy ⁴⁶⁷. A new non-enzyme, hydrogen peroxide-based formulation (not FDA-cleared) was as effective as enzymatic cleaners in removing protein, blood, carbohydrate, and endotoxin from surface test carriers ⁴⁶⁸ In addition, this product effected a 5-log ₁₀ reduction in microbial loads with a 3-minute exposure at room temperature. ⁴⁶⁸

Although the effectiveness of high-level disinfection and sterilization mandates effective cleaning, no "real-time" tests exist that can be employed in a clinical setting to verify cleaning. If such tests were commercially available they could be used to ensure an adequate level of cleaning. ⁴⁶⁹⁻⁴⁷² The only way to ensure adequate cleaning is to conduct a reprocessing verification test (e.g., microbiologic sampling), but this is not routinely recommended ⁴⁷³. Validation of the cleaning processes in a laboratory-testing program is possible by microorganism detection, chemical detection for organic contaminants, radionuclide tagging, and chemical detection for specific ions 426, 471. During the past few years, data have been published describing use of an artificial soil, protein, endotoxin, X-ray contrast medium, or blood to verify the manual or automated cleaning process 169, 452, 474-478 and adenosine triphosphate bioluminescence and microbiologic sampling to evaluate the effectiveness of environmental surface cleaning 170, 479. At a minimum, all instruments should be individually inspected and be visibly clean.

# data[].attributes.attachment_link.description
Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

# data[].attributes.attachment_link.readable_text
Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments.

Cleaning is done manually in use areas without mechanical units (e.g., ultrasonic cleaners or washer-disinfectors) or for fragile or difficult-to-clean instruments. With manual cleaning, the two essential components are friction and fluidics. Friction (e.g., rubbing/scrubbing the soiled area with a brush) is an old and dependable method. Fluidics (i.e., fluids under pressure) is used to remove soil and debris from internal channels after brushing and when the design does not allow passage of a brush through a channel. ⁴⁴⁵ When a washer-disinfector is used, care should be taken in loading instruments: hinged instruments should be opened fully to allow adequate contact with the detergent solution; stacking of instruments in washers should be avoided; and instruments should be disassembled as much as possible.

The most common types of mechanical or automatic cleaners are ultrasonic cleaners, washer-decontaminators, washer-disinfectors, and washer-sterilizers. Ultrasonic cleaning removes soil by cavitation and implosion in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces. Bacterial contamination can be present in used ultrasonic cleaning solutions (and other used detergent solutions) because these solutions generally do not make antibacterial label claims ⁴⁴⁶. Even though ultrasound alone does not significantly inactivate bacteria, sonication can act synergistically to increase the cidal efficacy of a disinfectant ⁴⁴⁷. Users of ultrasonic cleaners should be aware that the cleaning fluid could result in endotoxin contamination of surgical instruments, which could cause severe inflammatory reactions ⁴⁴⁸. Washer-sterilizers are modified steam sterilizers that clean by filling the chamber with water and detergent through which steam passes to provide agitation. Instruments are subsequently rinsed and subjected to a short steam-sterilization cycle. Another washer-sterilizer employs rotating spray arms for a wash cycle followed by a steam sterilization cycle at 285°F 449, 450. Washer-decontaminators/disinfectors act like a dishwasher that uses a combination of water circulation and detergents to remove soil. These units sometimes have a cycle that subjects the instruments to a heat process (e.g., 93ºC for 10 minutes) ⁴⁵¹. Washer-disinfectors are generally computer-controlled units for cleaning, disinfecting, and drying solid and hollow surgical and medical equipment. In one study, cleaning (measured as 5-6 log ₁₀ reduction) was achieved on surfaces that had adequate contact with the water flow in the machine ⁴⁵². Detailed information about cleaning and preparing supplies for terminal sterilization is provided by professional organizations 453, 454 and books ⁴⁵⁵. Studies have shown that manual and mechanical cleaning of endoscopes achieves approximately a 4-log ₁₀ reduction of contaminating organisms 83, 104, 456, 457. Thus, cleaning alone effectively reduces the number of microorganisms on contaminated equipment. In a quantitative analysis of residual protein contamination of reprocessed surgical instruments, median levels of residual protein contamination per instrument for five trays were 267, 260, 163, 456, and 756 µg ⁴⁵⁸. In another study, the median amount of protein from reprocessed surgical instruments from different hospitals ranged from 8 µg to 91 µg. ⁴⁵⁹ When manual methods were compared with automated methods for cleaning reusable accessory devices used for minimally invasive surgical procedures, the automated method was more efficient for cleaning biopsy forceps and ported and nonported laparoscopic devices and achieved a >99% reduction in soil parameters (i.e., protein, carbohydrate, hemoglobin) in the ported and nonported laparoscopic devices. 460, 461

For instrument cleaning, a neutral or near-neutral pH detergent solution commonly is used because such solutions generally provide the best material compatibility profile and good soil removal. Enzymes, usually proteases, sometimes are added to neutral pH solutions to assist in removing organic material. Enzymes in these formulations attack proteins that make up a large portion of common soil (e.g., blood, pus). Cleaning solutions also can contain lipases (enzymes active on fats) and amylases (enzymes active on starches). Enzymatic cleaners are not disinfectants, and proteinaceous enzymes can be inactivated by germicides. As with all chemicals, enzymes must be rinsed from the equipment or adverse reactions (e.g., fever, residual amounts of high-level disinfectants, proteinaceous residue) could result. 462, 463 Enzyme solutions should be used in accordance with manufacturer's instructions, which include proper dilution of the enzymatic detergent and contact with equipment for the amount of time specified on the label. ⁴⁶³ Detergent enzymes can result in asthma or other allergic effects in users. Neutral pH detergent solutions that contain enzymes are compatible with metals and other materials used in medical instruments and are the best choice for cleaning delicate medical instruments, especially flexible endoscopes ⁴⁵⁷. Alkaline-based cleaning agents are used for processing medical devices because they efficiently dissolve protein and fat residues ⁴⁶⁴; however, they can be corrosive. ⁴⁵⁷ Some data demonstrate that enzymatic cleaners are more effective than neutral detergents 465, 466 in removing microorganisms from surfaces but two more recent studies found no difference in cleaning efficiency between enzymatic and alkaline-based cleaners. 443, 464 Another study found no significant difference between enzymatic and non-enzymatic cleaners in terms of microbial cleaning efficacy ⁴⁶⁷. A new non-enzyme, hydrogen peroxide-based formulation (not FDA-cleared) was as effective as enzymatic cleaners in removing protein, blood, carbohydrate, and endotoxin from surface test carriers ⁴⁶⁸ In addition, this product effected a 5-log ₁₀ reduction in microbial loads with a 3-minute exposure at room temperature. ⁴⁶⁸

Although the effectiveness of high-level disinfection and sterilization mandates effective cleaning, no "real-time" tests exist that can be employed in a clinical setting to verify cleaning. If such tests were commercially available they could be used to ensure an adequate level of cleaning. ⁴⁶⁹⁻⁴⁷² The only way to ensure adequate cleaning is to conduct a reprocessing verification test (e.g., microbiologic sampling), but this is not routinely recommended ⁴⁷³. Validation of the cleaning processes in a laboratory-testing program is possible by microorganism detection, chemical detection for organic contaminants, radionuclide tagging, and chemical detection for specific ions 426, 471. During the past few years, data have been published describing use of an artificial soil, protein, endotoxin, X-ray contrast medium, or blood to verify the manual or automated cleaning process 169, 452, 474-478 and adenosine triphosphate bioluminescence and microbiologic sampling to evaluate the effectiveness of environmental surface cleaning 170, 479. At a minimum, all instruments should be individually inspected and be visibly clean.

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Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)